Details of any machinery or vehicle operators convicted of a criminal offence:

Please type N/A, if not applicable

Details of vehicle, if any Please list the Year/Make/Model,Security Devices,Serial Number / Rego and Sum insured for each vehicle:

Help us help you by answering this survey question: What type of roof do you have?:

Prior to entering into a contract of general insurance you have a duty to disclose certain information. You have the same duty to disclose prior to renewing, extending or varying a general insurance contract. When answering the questions you must be honest and you have a duty under law to tell us anything known to you. You, and of which a reasonable person in the known circumstances would include in answer to the questions. We use the answers in deciding whether to insure you and on what terms. If you do not answer the questions in this way, we may reduce or refuse to pay a claim, or cancel the policy. If you answer questions fraudulently, we may refuse to pay a claim and treat the policy as never have been valid.

Declaration:

I / We confirm we have read the Duty of Disclosure included in this application form and confirm the answers are true correct and that no information has been withheld which may affect the decision to accept this application or the terms and conditions.